Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288338 Renewal 05/26/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.145(1)Individual #1's 01/19/26 Emergency Medical Plan lists the Individual's preferred hospital as both "Lancaster General Hospital" and "Ephrata Community Hospital". Corrected on site.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. The Emergency Medical Plan was updated on 5/28/26 to consistently identify the individual's preferred hospital as Lancaster General Hospital (Attachment 2). 06/02/2026 Implemented
6400.181(d)Individual #1's most recent Annual Assessment was not signed or dated by the Program Specialist completing the document. Corrected on site.The program specialist shall sign and date the assessment. The Program Specialist signed and dated Individual #1's Annual Assessment while inspectors were on site. 06/11/2026 Implemented
6400.181(e)(10)Individual #1's most recent Annual Assessment does not include a complete medical history. Corrected on site.The assessment must include the following information: A lifetime medical history. The violation was corrected while inspectors were on site. 06/11/2026 Implemented
SIN-00250153 Renewal 09/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1's Date of Admission is 03/15/24 and the Initial Assessment was completed on 05/20/24, outside of the 60-day requirement. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The current program specialist has reviewed the section of the Pa Code 55 Chapter 6400 pertaining to initial assessment as of 10/4/24 and is aware to complete any initial assessment in a timely manner. A number of program specialists will be starting in November 2024. The CEO would ensure that they are trained on the timelines for completing various documents for individuals on their caseloads. 10/04/2024 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 02/03/2020, stating that individuals have additional rights they need to be informed of. At the time of the 09/24/2024 annual inspection, Individual #1 was never informed of the individual rights as described in 6400.32; specifically, 32(b), 32(r)1, 32(r)3, 32(s)1, 32(v), 33(a), 33(b) were not identified on the form.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.An updated Individual Rights Document has been reviewed with Individual #2 as of 9/26/24 (see attachment # 3). It is worth noting that on the day of admission (3/15/24), Individual #2 was given keys to the home and the bedroom. The records of the other individual supported by the agency contained an Individual Rights Document that was in compliance with the requirements of the 6400 regulations. This was verified by the ODP licensing team during their visit. 10/04/2024 Implemented
SIN-00272005 Renewal 09/02/2025 Compliant - Finalized
SIN-00232902 Renewal 10/31/2023 Compliant - Finalized